Association of β-blocker therapy at discharge with clinical outcomes after acute coronary syndrome in patients without heart failure

• Chen Y.
• Tang X.-F.
• Gao R.-L.
• Yang Y.-J.
• Xu B.
• Yuan J.-Q.

Abstract

Aim - to evaluate the clinical impact of β-blocker in patients with adequate left ventricular ejection function (LVEF) who underwent percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS).

Methods. A total of 10,724 consecutive patients who underwent PCI throughout 2013 were prospectively enrolled in the study. Among these, we analyzed 5,631 ACS patients who were discharged with LVEF ≥40%. Patients were then compared according to the β-blocker prescription at discharge.

Results. During a 2-year follow-up, no significant association was observed of β-blocker use with all-cause mortality: with β-blockers 47/5,043 (0.9%) vs without β-blocker use 8/588 (1.4%); hazard ratio (HR) 0.762; 95% confidence interval 0.36 to 1.64; p=0.485), cardiac death, myocardial infarction (MI), or major adverse cardiovascular and cerebrovascular events. Subgroup analysis demonstrated that the β-blocker use at discharge reduced the 2-year mortality in patients with unstable angina (UA) (HR 0.42; 95% CI 0.19 to 0.94; p=0.034). Landmark analysis at 1 year showed that patients with UA who were discharged with β-blockers had lower mortality (HR 0.17; 95% CI 0.04-0.65, p=0.010) and cardiac death (HR 0.12; 95% CI 0.01-0.99, p=0.049) than those discharged without β-blockers. However, the benefit was lost beyond 1 year. No differences in outcomes were recorded in the AMI or overall population.

Conclusions. We present that β-blocker significantly lowers the rate of all-cause death up to 1 year, in UA patients who have undergone PCI and have adequate LVEF. Its role in patients with AMI also deserves further exploration.

REFERENCES

1. Roffi M., Patrono C., Collet J.P., et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37 (3): 267-315.

2. O'Gara P.T., Kushner F.G., Ascheim D.D., et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2013; 61 (4): e78-140.

3. Amsterdam E.A., Wenger N.K., Brindis R.G., et al. 2014 AHA/ ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014; 64 (24): e139-228.

4. Authors/Task Force Members; Steg G., James S.K., et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eu Heart J. 2012; 33 (20): 2569-19.

5. Ibanez B., James S., Agewall S., et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39 (2): 119-77.

6. Freemantle N., Cleland J., Young P, Mason J., Harrison J. Beta-blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999; 318 (7200): 1730-7.

7. Chatterjee S., Biondi-Zoccai G., Abbate A., et al. Benefits of beta-blockers in patients with heart failure and reduced ejection fraction: network meta-analysis. BMJ. 2013; 346 (1): f55.

8. Lee Y.H., Park J.S., Tahk S.J., et al. Beta-blocker therapy in the era of primary percutaneous intervention for ST elevation myocardial infarction. Cardiology. 2015; 132 (2): 91-100.

9. Puymirat E., Riant E., Aissoui N., et al. Beta-blockers and mortality after myocardial infarction in patients without heart failure: multicentre prospective cohort study. BMJ. 2016; 354: i4801.

10. Ozasa N., Morimoto T., Bao B., et al. Beta-blocker use in patients after percutaneous coronary interventions: one size fits all? Worse outcomes in patients without myocardial infarction or heart failure. Int J Cardiol. 2013; 168 (2): 774 - 9.

11. Bangalore S., Makani H., Radford M., et al. Clinical outcomes with в-blockers for myocardial infarction: a meta-analysis of randomized trials. Am J Med. 2014; 127 (10): 939-53.

12. Hori M., Sasayama S., Kitabatake A., et al. Low-dose carvedilol improves left ventricular function and reduces cardiovascular hospitalization in Japanese patients with chronic heart failure: the Multicenter Carvedilol Heart Failure Dose Assessment (MUCHA) trial. Am Heart J. 2004; 147 (2): 324-30.

13. Levine G.N., Bates E.R., Blankenship J.C., et al. 2011 ACCF/ AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011; 124 (23): e574-651.

14. Smith S.C. Jr, Benjamin E.J., Bonow R.O., et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Circulation. 2011; 124 (22): 2458-73.

15. Thygesen K., Alpert J.S., Jaffe A.S., et al. Third universal definition of myocardial infarction. Eur Heart J. 2012; 33 (20): 2551-67.

16. Jneid H., Anderson J.L., Wright R.S., et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2012; 60 (7): 645-81.

17. Dondo T.B., Hall M., West R.M., et al. Beta-blockers and mortality after acute myocardial infarction in patients without heart failure or ventricular dysfunction. J Am Coll Cardiol. 2017; 69 (22): 2710-20.

18. Huang B.T., Huang F.Y., Zuo Z.L., et al. Meta-analysis of relation between oral в-blocker therapy and outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention. Am J Cardiol. 2015; 115 (11): 1529-38.

19. Li C., Sun Y., Shen X., et al. Relationship between beta-blocker therapy at discharge and clinical outcomes in patients with acute coronary syndrome undergoing percutaneous coronary intervention. J Am Heart Assoc. 2016; 5 (11): e004190.

20. Yang J.H., Hahn J.Y., Song Y.B., et al. Association of beta-blocker therapy at discharge with clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. JACC Cardiovasc Interv. 2014; 7 (6): 592-601.

21. Nakatani D., Sakata Y., Suna S., et al. Impact of beta blockade therapy on long-term mortality after ST-segment elevation acute myocardial infarction in the percutaneous coronary intervention era. Am J Cardiol. 2013; 111 (4): 457-64.

22. Bramlage P., Messer C., Bitterlich N., et al. The effect of optimal medical therapy on 1-year mortality after acute myocardial infarction. Heart. 2010; 96 (8): 604-9.

All articles in our journal are distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0 license)